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08/29/2003 FRI 05:49 FAX 661 93 3834 MP ENVIRONMENTAL-BAB0 X1006/006 <br /> Mar•22. 2003 4: 16PM Glar ' ,r Environmental No-0364 P. 10 <br /> SAN IOA,QYJi?11 COUNTY PUBLIC Et✓ALTR SERVTCU <br /> VMMON ENTAL Z MALTH DIMION <br /> UNDFRGROLM STORAGE TANK DMOSMON TRACKING RRCORD <br /> A'000*06Me Owe 660UlkllMkkR®Pgelip`!h'aw■/p ri k*00*nrep4y41"M******N!lMMPNi.errelkMRpMM4•dfli}l46reMk4hyOklli}*!r®! <br /> SECTION 1-Public Health Services hvironmentat Atalth Divislnn Tank'Iltackfttg Sheet shall aeeompaoy eaeb Unk afSxed wfth <br /> its site identification n=ber. The Tank Tracldng Sheet is to be returned to Public Health Services BaVkonffMMW I•iealtlt DiVWM <br /> within 30 dans of acceptance of the tank by the disposal or ret>yeling fsCiiity. The permit holder is responsible ibr assuring gM <br /> this tbrat is ttnnpleted and returned. <br /> FACILITY NAME: y7 <br /> PACILM ADDRESS: 3t°. a S�„� A- <br /> TANK ID#39- 501-7-r-IT TANK SIZE: PnVIOUS TANK CON'T'ENTS: <br /> k.rapyteMkra■lasrauelwr4tm+��ellkmleM�rn4ar+nklk*p4raaa�ia*tal4rr�rs#4am*�4e+f*4Fid�m�M9b`�krkkrrlkr®wMM�s*oarr <br /> SECTION 2•To be filled out by tank removal eontmctor; <br /> Tank Removal Contractor, (T�ctiec2r 6% ✓ , i,+�., <br /> Address: LPI(a i2 J 5�& 1 1 `1Z•ti Cit,; zip: S'tlz, <br /> Data Tants Removed, <br /> ' ■yywNrerkfpkRmkkMeir�r�bltbr®eel4ll**akrlrrrr**i�!lwlNMlhsg®Rkkok!l/koakrrggr!!!®®klkpbktt�*r*m*�eq,lrlr+year#w+ <br /> SECTION 3•To be tilled out by contractor"decontaminating teak": <br /> Thak Decoutamirmlon Coutmetoc: ri ra-� t�...�• .4 <br /> Add 3�f�a� 1'Zt�w xti. S key. <br /> City; c3ae.a ZIP!, 9 33 U <br /> Phone A <br /> Authorized mpromitative of eontraetnr certifying thfottdlt sigrratttre below that the tank hes bma decontamltrtrtcd in as spprovGd <br /> meaner as required by Cal EPA. <br /> ?Jame: 64ft OSR A N t0771 'Title. t?jco,E- en 9,e ,—Signattu'e: A0 Date 5' e' <br /> yalklNkykyak*M■�dma*eeeyeeerwarkyeewawq***aaraalNe!!y!!!lMyywryiW60me#mh**a*s*VVs*q*****Vsee wasoftekkka***of <br /> SECTION 4.To bo olgaed and dated by as authorized rWeemeative of the atramxeae,moorage,or dispeaal titcility <br /> zcceptlag Ma=d/or piping, <br /> Paeillty D C-A-1 57A-7Z-:- !77 157i;K 5- <br /> ess•- sku'!LJ1�l$�C Gilk.,, Ci -zsZSx-iCto <br /> Addr <br /> ryt• <br /> Phow h&Lob �' -�� <br /> u <br /> Date T'aak Received: -:366 <br /> erk*myk4we*44f4f#*Mlwwfleeewk*♦gwae44♦4■4pTA�k4rtyklykylytaeu!#***p*ykRR4ky4yH!lNryes4�.et4l4!**e+RllgR4! <br /> EH 23 046 (RavWd W13/99) Page 10 <br />